Sharp Party Differences on Health Care Shape the Election Campaign

BOSTON, Jan. 24 -- Republican and Democratic voters are sharply divided about four health care issues that could affect not only their choice of candidate, but also critical policy decisions in the next administration, researchers found.

There are significant differences by political party affiliation, at P<0.001 for all, in attitudes about President Bush's handling of health care, the general state of the health care system, the individual's own care, and solutions to health care problems, Robert J. Blendon, Sc.D., of the Harvard School of Public Health, and colleagues reported in the Jan. 24 issue of the New England Journal of Medicine.

"Although Americans agree that health care is an important problem, there are huge differences between Republicans and Democrats on what should be done to improve it," said Dr. Blendon.

In broad strokes, Democratic primary voters believe there is so much wrong that the health care system needs to be completely rebuilt. Republicans are considerably more satisfied with the cost and quality of their own care and don't see a crisis needing a major overhaul of the system.

That sharp disagreement is one reason it will be difficult to achieve political consensus on reform in the new administration, the researchers concluded.

To explore the role of health care in the 2008 presidential campaign, the researchers surveyed registered voters in the District of Columbia and 35 states with primaries or caucuses in January or February.

The 1,182 respondents were categorized as Republican (508) or Democrat (674) on the basis of their likelihood of voting in the primary or caucus of that party.

The telephone survey, a joint venture between the Harvard School of Public Health and the Kaiser Family Foundation, was conducted from Nov. 1 through Nov. 11, 2007 and responses were statistically weighted to reflect the U.S. population.

The researchers also considered data from 10 other recent surveys by national media polling organizations.

Among the findings:

43% of Republicans approved of Bush's handling of health care compared with 14% of Democrats

44% of Republicans rated the nation's health care system as excellent, but only 20% of Democrats gave it those high marks

66% of Republicans are dissatisfied with the cost of health care in the U.S. compared with 89% of Democrats

58% of Republicans are satisfied with the quality of care in the U.S. but only 20% of Democrats feel that way

When asked to categorize their own personal situation, 39% of Republicans and 61% of Democrats were dissatisfied with their own health care costs.

A similar shift was evident when it came to quality of care, with 90% of Republicans and 74% of Democrats satisfied with it.

For instance, asked whose responsibility it is to ensure that people have health insurance, three times as many Democrats (39%) said "government" than Republicans (13%). Forty-five percent of GOP voters say it's an individual's responsibility.

And, while voters in both parties are concerned about the number of uninsured Americans, 74% of Democrats are willing to pay higher taxes to assure universal coverage, compared with 46% of Republicans.

There's also a deep divide on the issue of mandated coverage - with 74% of Democrats favoring a requirement that all Americans purchase health insurance with government helping to pay for the poor. A majority (53%) of Republicans opposed such a mandate.

Legalized abortion and federal funding for embryonic stem cell research remain contentious issues. Most Republicans oppose both while most Democrats favor them.

The issues are crucial for many voters: 29% of Republicans and 26% of Democrats say they would only vote for a candidate who shares their view about abortion.

The overall personal satisfaction level plus the wide divergence of opinion about health care may thwart efforts to reform the health care system, the authors note.

"The future of health reform really depends on the course the general election takes, Dr. Blendon said in an interview. "The Republican candidate will really feel that he has a much different mandate than the Democratic candidate."

"Finding a way to bridge those differences will be important to winning independents in the general election and to fashioning a legislative compromise in the new Congress in 2009," said co-author Drew E. Altman, Ph.D., president of the Kaiser Family Foundation.

Other recent voter surveys have reached conclusions that differ from those presented by Blendon and colleagues.

In a survey by the Commonwealth Fund, a liberal independent foundation, 81% of Americans said that employers should either provide health insurance to their workers or contribute to the cost of their coverage. Nearly 90% of Democrats, 73% of Republicans, and 79% of independents said they would support such an employer "play or pay" requirement.

That survey also found that a wide majority of Democratic (67%), Republican (66%), and independent (70%) voters believe that health insurance costs should be shared by individuals, employers, and the government.

A majority of the public was strongly or somewhat in favor of requiring individuals to have health insurance coverage, with government help for those who cannot afford it. Sixty-eight percent of Americans favored such a proposal, with 80% of Democrats, 52% of Republicans, and 68% of independents in favor of the approach.

Finally, a Wall Street Journal-NBC News Poll found that by a margin of 49% to 40%, Americans back more conservative health care solutions of tax credits and health-savings accounts over government mandated coverage backed by subsidies for the poor. But, by 51% to 42%, they back the liberal idea of tax increases on the rich to expand coverage over continued tax cuts.

Reviewed by Zalman S. Agus, MD Emeritus Professor University of Pennsylvania School of Medicine

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